Through GCI’s Fellowships and Scholarships, young oncologists from low- and middle-income countries have the opportunity to come to Boston and gain exposure to clinical practices, education, and research in the U.S. They participate in all of the projects we do here at GCI, from leading research publications on cancer control in their home countries to designing access-to-care initiatives to help their patients back home. Dr. Rossana Ruiz is an oncologist at the Instituto Nacional de Enfermedades Neoplásicas, in Lima, Peru, and has been our Fellow since October 2015. Rossana has been such a wonderful and energetic addition to our team here in Boston, and in the last week of her Fellowship, I was able to chat with her about her time in Boston, the projects she has been working on, and the lessons she will carry back with her when she returns to Peru.

Alexandra: Could you tell us a little bit about your background and what you do?

Rossana: I am a Peruvian oncologist, and I completed my medical training at the Peruvian National Cancer Institute, INEN. After I finished my residency in Clinical Oncology in 2014, I worked as a medical oncology attending for adolescents and young adults with hematological malignancies for almost a year, which was the most fulfilling and gratifying experience I have had as a clinician. I am fascinated by the challenge of understanding and treating cancer in the young, and, since then, I have been working on projects and publications on this special population of patients. Then in October 2015, I started my fellowship at the Global Cancer Institute.

A: How do you like Boston?

R: I am in love with Boston and you know it! This is a great city to live in and enjoy; it is organized, safe, and beautiful. As it is a university city, its population is friendly, multicultural, and highly educated, which I think is an awesome combination. In its streets, authentic history mixes with a youth vibe to create a unique atmosphere. A wide variety of cultural and musical activities await around every corner, at every time, and are accessible for everyone. Plus, it is very easy to get around the city – you can just walk anywhere while admiring the views! Being able to go the Charles River Esplanade just for lunch or just walk through Boston’s amazing parks on a sunny – or snowy – day is something I am definitely going to miss. In fact, as Dr. Goss told me on the day I arrived, a piece of my heart will remain in Boston forever.

A: What has been your favorite experience so far in your Fellowship?

R: One of the experiences that I have enjoyed the most is being able to experience real teamwork and being treated as peer for every single project. It is amazing how when people work together, knowledge and unique perspectives blend, and creativity booms to reach a common goal. It has been an honor to work with a network of such intelligent and passionate, yet humble, people here in Boston and around the world! I have had the opportunity to meet so many of these people individually, and it gives me great satisfaction to consider them my colleagues and outstanding role models, but above all, great friends.

A: What kinds of projects are you working on here with Dr. Goss and GCI? What projects or ideas are you most excited about sharing with your colleagues and starting at your hospital when you get back to Lima?

R: I have worked with very talented colleagues under the mentorship of Dr. Goss on various projects, ranging from current clinical topics in oncology to purely public health issues. We designed and conducted a survey to assess the patterns of clinical practice of more than 3,000 breast cancer specialists across Latin America, with the objective of identifying adherence to clinical practice guidelines and its determinants. The results of this assessment will constitute the framework for implementing targeted educational interventions that will aid in improving clinical care. We have also analyzed the worrisome situation of access to high-cost cancer drugs across Latin America and proposed feasible ways to overcome its multiple challenges, all from a physician’s perspective. Currently, we are working on implementing a Patient Navigation Program, as well as a very promising protocol to identify factors that predispose a certain group of young women to a deadly form of breast cancer that is related to pregnancy. Once back in Lima, I am very excited to start working right away on a multicenter database for young breast cancer patients, a highly impactful but understudied disease, more frequently seen in my region of the world.

A: What do you think will be your biggest take-away or lesson learned from your time here at GCI?

R: Being in Boston has been a game-changing experience for me. Besides my personal growth, working with GCI has allowed me to take time to analyze the Latin American cancer situation from a wider, mentored perspective. Our problems transcend individual jurisdictional boundaries and are common to the region, and that is why collaboration is so relevant. I learned that along the continuum of cancer care – from prevention to primary treatment and supportive care – there are multiple deficiencies that, when added up, drive the huge difference in cancer mortality between our countries and the Western world. One of the most important take-home messages for me is that every gap or barrier represents an opportunity for improvement. Therefore, each barrier needs to be properly identified, researched, and documented in order to construct goal-driven and evidence-based interventions. In this way, we obtain effective and reproducible solutions that are amenable to be applied to bigger populations.

A: What advice would you give to young oncologists, doctors, or students who are thinking about getting into public health or cancer research?

R: Cancer incidence and mortality is expected to markedly increase in developing countries like mine in the following years. In our everyday practice, health inequities and the deficiencies and weaknesses of our healthcare system (evidenced by the high prevalence of advanced disease in developing countries) just jump out at us. In this setting, a public health perspective cannot be disconnected from the practice of oncology. Research is for sure the first step, and the opportunities are endless and frequently at the patient’s bedside. Doctors and researchers, especially through collaborative networks, are in a strategic position to draw authorities and public attention to our reality and our needs.

Health system fragmentation is common in low- and middle-income countries. Most countries in Latin America have fragmented health systems with many different health coverage schemes – none of which are universal, and most of which exclude the poorest and most vulnerable patients. The result? A large proportion of patients who need care the most cannot access it, especially for complex chronic diseases like cancer.

What is health system fragmentation?

Health system fragmentation happens when there are many different health “subsystems” that coexist, providing care for different parts of a country’s population. Each of these subsystems has their own way of financing and delivering healthcare, and each provides healthcare to different types of people. For example, one subsystem will provide coverage for government workers, another will cover formally employed persons, and yet another will attempt to provide basic health benefits for the unemployed, etc.

What is the problem?

The problem is that when these subsystems operate independently from one another, they create major gaps in the provision of health services, often leaving out the poorest patients. Overall, fragmented health systems are less efficient, and provide fewer resources to those who need care the most, leading to great health inequities throughout a country. The issues arising from health system fragmentation are compounded by the fact that many health systems are not well funded by government spending in the first place, especially for chronic diseases like cancer. In fact, while Latin America spends an average of 7.7% of its GDP on cancer care, the U.S. spent nearly 18% of its GDP. Now imagine this small amount of money being used inefficiently and spread over a much larger population. Low- and middle-income countries represent 85% of the world’s population and 61% of new cancer cases globally, but they account for only 6% of global expenditures on cancer care.

A major barrier to accessing care

Fragmented health systems are very difficult for patients to navigate. Trying to move from a primary care center to a more specialized cancer center can be confusing, difficult, or even impossible if a patient doesn’t have proper insurance coverage. Because of this, fragmentation causes delays in diagnosis and initiating treatment, leading to late-stage disease and high mortality rates. Patients throughout Latin America have low screening rates, delayed referrals, and sometimes won’t even seek medical help because of these barriers.

“Catastrophic out-of-pocket expenses”

When health systems are fragmented (and not well-funded to begin with), they require high out-of-pocket expenses from patients at the hospital when they seek health care. Now imagine a family without health insurance, or even an inadequate public health insurance. If a member of that family is diagnosed with cancer, they would face health payments that would drive them into poverty – what we call “catastrophic out-of-pocket expenses.” In 2008, it was estimated that ⅓ of the people in Latin America were considered at high risk for such impoverishment due to catastrophic health expenditures.

Moving toward Universal Health Coverage

The WHO, in partnership with the World Bank, developed an agenda in 2015 to move towards universal health coverage (UHC) worldwide. It is clear that there are major gaps in the provisions of healthcare around the world: over 400 million people do not have access to one or more essential health services. Universal health coverage, in the form of national insurance schemes provided by governments, would not only ensure that basic health care is provided to everyone in that country, but would make the provision of health services more efficient and more equitable.

Importantly, the move toward basic universalism is targeted towards the poorest sectors – the most vulnerable patients with the most barriers to care. Latin American countries have begun to move in this direction by creating special agencies to provide basic care for those who were previously uninsured. Due to this expansion of basic coverage, the proportion of people covered by insurance systems in Latin America grew from 46% to 60% between 2008 and 2013.

How to improve patient care now

The move toward universal health coverage will take time and will be more difficult for some countries than others. However, there are ways we can work within the broken systems that currently exist to help patients access the care they desperately need now. For example, through our Patient Navigation Programs, navigators facilitate patients’ passage through fragmented and complex health systems. They help underserved patients access health resources and overcome barriers they may encounter while trying to get cancer care, like making referral appointments and coordinating insurance paperwork. By providing patients with a knowledgeable resource and support system, navigators can help alleviate some of those systematic barriers to care that would usually stop patients in their tracks when trying to access the care they need.

GCI recently hosted a Global Tumor Board Special Session on genetic profiling for metastatic breast cancer, led by Dr. Ben Park from Johns Hopkins and Dr. Aditya Bardia from Massachusetts General Hospital. Genetic profiling is a way to analyze patient tumor samples and analyze on a molecular level the alterations that are unique to different tumors. A new and exciting field, the goal of genetic profiling is to create targeted therapies for cancer patients, based on their unique genetic sequence.

While this technique has great potential for advancing the field of cancer research, its benefits may not be accessible for most cancer patients in low- and middle-income countries (LMICs):

First, genetic sequencing is very expensive, with single tests ranging from $3,000 to $5,000 for a single patient. The final cost increases from there when considering the price of the personalized treatment plan that results from the genetic analysis. This price tag is too high for most, especially for patients who can barely afford standard cancer care.

Second, sequencing requires efficient and streamlined laboratory networks – samples need to be collected and delivered to the lab within hours, and the sequencing itself requires advanced tools and techniques. For many fragmented health systems with few resources, this may be too tall an order.

Finally, even clinical trials – one way many disadvantaged cancer patients are able to receive at least some sort of cancer therapy – may be largely inaccessible for patients in LMICs in this case. The majority of genetic profiling clinical trials are likely to be remain in high-income countries due to the aforementioned barriers in LMICs.

So, is there anything that can be done to share the technological advances of the U.S. and other wealthy nations with the millions of cancer patients in LMICs? Of course, over many years these genetic profiling techniques will get older, become cheaper as newer techniques are developed, and make their way to lower income countries (this happens with many things: TVs, iPhones, and even cancer therapies considered “old school” in the U.S. that have become more mainstream in LMICs.)

Rather than sitting back and waiting for this day to come, Dr. Park said that there a few promising paths that can be considered now:

Technology: Currently, “next generation sequencing” (or “NGS”) requires expensive machines and materials. But technology is getting better, faster, and cheaper. Dr. Park imagines that, in the future, we could see “portable kits” for community oncologists to use to sequence quickly, easily, and for low costs. In fact, several companies are continuously updating both their hardware and software – technologies are on the horizon where sequencers may even be plugged into a USB port.

Education: Educating community oncologists, both in the U.S. and in LMICs, is another important and inexpensive way to progress the field and start building capacity for when the technology does become available. Lectures, like this one hosted by GCI as part of our Global Tumor Boards, are a good first step, but a more systematic approach is needed to help oncologists understand and interpret genomic tests, information, and how they can help guide therapies.

Philanthropy: Philanthropic organizations could support the creation of a “pipeline” whereby patients’ tumor samples can be processed and shipped from LMICs to the U.S., analyzed, and the results sent back to physicians.

However, this last point would also mandate that drugs and trials be available for these patients once they get the results of their sequencing, which Dr. Park says is a much more difficult issue. Personalized therapies are prohibitively expensive and therefore inaccessible to most patients in LMICs (in fact, many personalized therapies are not even covered by insurance providers in the U.S.) So, unless drugs and clinical trials become accessible to these patients – or the pharmaceutical companies bend to allow greater access to high-cost meds for the majority of the world’s population – there would be no utility in making the genetic profiling technology available. Dr. Park concluded, “It has to be an end-to-end solution.”

GCI collaborators recently published an extensive review article “Cervical Cancer Control in Latin America: A Call to Action,” led by Dr. Brittany Bychkovsky. The paper outlined the current state of HPV vaccination and cervical cancer screening in Latin America, and noted the challenges of a successful campaign against cervical cancer throughout the region.

Here are some key facts from the paper:

Human papillomavirus (HPV) is the most common sexually transmitted infection worldwide

Deaths from cervical cancer are 100% preventable by vaccination and screening

<55% of eligible women in Latin America received a recent Pap test

Although 80% of young girls in Latin America live in countries with an HPV immunization program, the majority of girls lack access to receive and complete the vaccine series

The paper concluded with a call to action to improve cervical cancer control throughout Latin America. Dr. Bychkovsky and her team put forth some possible strategies for controlling cervical cancer in Latin America moving forward:

Primary prevention (HPV vaccination): The Pan American Health Organization (PAHO) recommends that HPV vaccination be introduced only if the immunization program is public, targets the whole country, and gradually increases its rates to achieve high coverage. The most important factors to consider include:

Coverage: The incidence of cervical cancer will be reduced if vaccination coverage is high (>70%).

Cost: The HPV vaccine should be procured at reduced rates so the program may be cost-effective for the LMICs of Latin America.

Target population: All vaccination plans in Latin America recommend vaccinating preadolescent girls between 9 and 12 years of age.

Dose: PAHO and WHO recommend introducing the vaccine on a 3-dose or 2-dose schedule (studies have shown that the 2-dose will likely become the new standard in Latin America.)

Administration: Vaccination programs will be most successful if integrated into schools.

Monitoring: Programs must be monitored to ensure efficacy, efficiency, and cost-effectiveness.

Secondary prevention (screening): In addition to HPV vaccination, screening will remain essential because it can take decades for HPV vaccination to have substantial effects on cervical cancer incidence. The team put forth some strategies for optimal screening practices:

Novel approaches: Mobile HPV screening programs, like one implemented in Panama, are effective in reducing cervical cancer incidence and are able to reach the most underserved communities.

HPV-DNA testing: This has proven to be effective as a stand-alone test for screening, and allows self-sampling, which increases participation rates among women in Latin America.

Patient education: Educational initiatives are essential for increasing awareness, especially among disenfranchised and rural populations. This can be done through media campaigns, or through the use of patient navigation programs (PNPs).

Patient navigators: PNPs not only help increase awareness and education on cervical cancer prevention, but they also help assist positively screened women with accessing timely follow-up care and health resources.

https://globalcancerinstitute.org/wp-content/uploads/2016/03/PN-MC-blog-photo-1.jpg23043456Alexandra Bukowskihttp://globalcancerinstitute.org/wp-content/uploads/2015/10/GCI_Logo_Main_2line_MedRez-340x156-300x138.pngAlexandra Bukowski2016-03-11 14:15:012017-05-31 18:59:54Launching a Patient Navigation Program in Mexico City